Hurricane Katrina/Rita Housing Assistance

Declaration of Funds Use and Continuing Need for Housing

Applicant’s Information			FEMA Registration # __________________
______________________________________________________________________________ 
(Last, First Middle Initial)
______________________________________________________________________________ 
(Street Address – Damaged)
______________________________________________________________________________ 
(City, County, State)
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I herby declare, under penalty of perjury that (check all that apply)

____ I received the initial assistance prior to receiving official written notification through the mail 
explaining the intended use of the rental assistance.

____ I used all or part of the rental assistance on serious and essential needs (e.g., food, clothing), 
because I lacked sufficient additional funding to address those needs.

____ I have a continuing need for Housing.

************************************

For Continued, Future Housing Assistance:

I understand that financial assistance for rental of temporary housing is only provided when FEMA 
determines that the individual’s residence is destroyed, uninhabitable, or inaccessible.  
I understand that in order to be considered for continued rent assistance I must submit rent receipts to 
show that I have exhausted the FEMA rent funds.
I understand that in order to be considered for continued rent assistance I must establish a realistic 
permanent housing plan and provide documentation showing that I am making efforts to obtain 
permanent housing. 
I understand that, if I intentionally make false statements or conceal any information in an attempt to 
obtain additional disaster aid, it is a violation of federal and State laws, which carry severe criminal and 
civil penalties, including a fine up to $250,000, imprisonment, or both.



Applicant Signature _________________________________________ Date___________